Top hospital cover

Find out how top hospital cover differs from other levels and how you can benefit from top hospital insurance.

Private hospital insurance provides additional cover for in-hospital services not covered by Medicare. It differs from public hospital cover in that:

• You can choose your own treating doctor or specialist
• You can choose to have a private or shared room in a public or private hospital
• You’ll experience shorter waiting times than those in the public system

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There are different levels of private hospital insurance available, but not all of them cover everything you may need, so for complete peace of mind, many people choose to take out top hospital health insurance. This is the highest level of cover available and covers private hospital treatment for all services where Medicare pays a benefit. The four levels of hospital cover are:

• Top cover. Top hospital covers all services where Medicare pays a benefit.
• Medium cover. Medium cover provides all the benefits offered by a basic policy in addition to other services, which may include joint replacement or birth related services. Restrictions and exclusions apply.
• Basic cover. Basic in-hospital cover usually excludes a range of services including non-cosmetic plastic surgery, psychiatric services and rehab.
• Public hospital. Public hospital cover provides you with the minimum benefits for treatment in a public hospital.

While top hospital cover is more expensive than other levels of private hospital cover, the costs can be offset somewhat by choosing to pay an excess or a co-payment.

What is an excess?

An excess is an additional amount you contribute towards the cost of a service, while a co-payment is a daily amount you pay towards your costs for every day you are in hospital. With one or both of these included in your policy, you can substantially reduce the cost of your premiums.

What does top hospital cover?

While basic and medium levels of private hospital cover restrict or exclude a range of services, top hospital cover includes every service where Medicare pays a benefit. That means, where lower levels of cover won’t include things like pregnancy and birth related services, assisted reproductive services, cataract and eye lens procedures, joint replacements and renal dialysis, top hospital will cover them all. A good top hospital policy will also cover services like:

• 100% emergency ambulance services
• Tonsils, adenoids and appendix removal
• Surgical removal of wisdom teeth
• Colonoscopies
• Palliative care
• Spinal fusion
• Psychiatric treatment
• Rehabilitation treatment
• Heart-related medical and surgical admissions
• Plastic and reconstructive surgery
• Weight loss surgery such as gastric banding

What top hospital options are available from the finder.com.au panel?

• AHM Top Hospital 500: Provides the same protection as offered by AHM Deluxe Hospital in addition to cover for a range of commonly excluded services such as weight loss surgery, sterility reversal and obstetrics.

• Health.com.au High Hospital: Provides comprehensive cover on everything from heart surgery to pregnancy related services, as well as offering a refund of up to 85% on the cost of certain types of extras cover taken out with any fund.

• HIF GoldStar Hospital: Delivers a premium service, covering a multitude of treatments as well as theatre fees, ward fees and maternity services. Includes flexible excess options and a 4% discount when 1 years premium is paid upfront.

• Australian Unity Platinum Hospital: Designed for those who want top tier hospital cover that insures them for all Medicare approved treatments as well as heart, fertility and pregnancy services.

• GMHBA Gold Hospital: Covers a wide range of hospital-related treatments and procedures including general and major dental. Medical gap cover is included so no surprise out-of-pocket expenses. A family orientated version of this cover is also available, which comes with orthodontic benefits that increase over time and no hospital excess for kids.

• HCF Premium Hospital: All-inclusive top hospital cover that comes with all the benefits of HCF’s lower-tier private hospital insurance while adding cover for pregnancy services and unlocking a range of exclusive extras options. Rewards policy holders with increasing limits for each year they stay insured.

• NIB Top Hospital: Complete hospital insurance that covers a wide scope of treatments from dental to brain surgery. Also grants benefit eligibility for obesity, pregnancy and assisted reproductive services as well as limited cover for psychiatric care.

• Transport Health Top Hospital: Provides cover for the widest range of hospital treatments and procedures in addition to those not usually covered by lower-tier cover like heart surgery, pregnancy services and knee reconstruction. Includes the ability to choose between paying an excess, a co-payment or neither.

Who can benefit from top hospital cover?

Two of the main benefits offered by top hospital private health insurance, that are often not included in lower levels of cover, are assisted reproductive services and cataract and eye-related services. So if you are planning to start a family and are looking at procedures such as IVF (In-Vitro Fertilisation) or GIFT (Gamete Intrafallopian Transfer), both of which can be expensive with no guarantees of success, having top hospital insurance to cover the in-hospital portion of these procedures can be highly beneficial. You will still have some out-of-pocket expenses for services performed outside of hospital, such as specialist visits and various tests, but the hospital part will be covered up to certain benefit limits. Similarly with eye-related services such as cataract removal or refractive lens exchange (RLE), having top hospital cover for the in-hospital portion of the procedure will go a long way towards covering your costs. Medicare provides a rebate for part of the cost and your top hospital insurance will cover some or all of the rest.

Have more health insurance questions? Head to our comprehensive FAQs page

Are there any exclusions?

Despite providing top level protection, there are some things even top hospital private health insurance will not cover. The main ones are:

• Services performed outside of Australia. Surgical procedures and associated costs incurred in another country will not be covered. If you’re planning to save money by having an operation overseas (often referred to as medical tourism), don’t expect your top hospital insurance to pick up the tab.
• Services that are not deemed clinically necessary. Services such as cosmetic surgery, which do not attract a Medicare rebate because they are not considered medically necessary, are also not covered by top hospital cover.

Beware the gap

The main thing to be aware of with any of these in-hospital services is that if your doctor or specialist charges more than the Medicare Benefit Schedule (MBS) fee, there is likely to be a “gap” between what Medicare will cover (75% of the MBS fee) and what your top hospital insurance will reimburse you (25% of the MBS fee). This will result in an out-of-pocket expense, unless your health fund has a Medical Gap Scheme to help cover the difference. If your doctor or specialist participates in their particular scheme, then you won’t have to pay any gap costs. It’s important to talk to your fund before being admitted to hospital to make sure you are fully covered by your top hospital insurance.

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